Inspection on 03/05/07 for Westhill Care Home

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westhill Care Home 30/01/06

Westhill Care Home 22/11/04

Westhill Care Home 10/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 39 Westway Westhill Care Homes 39 Westway Caterham Surrey CR3 5TQ Lead Inspector Mary Williamson Unannounced Inspection 3rd May 2007 11:00 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 39 Westway Address Westhill Care Homes 39 Westway Caterham Surrey CR3 5TQ 01883 382576 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) roshanwest@aol.com Mr Roshan Panchoo Mr Roshan Panchoo Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (1) registration, with number of places 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 35 - 65 years. Any person accommodated within the category of sensory impairment will only have a hearing loss/deafness. 30th January 2006 Date of last inspection Brief Description of the Service: The home is comprised of a converted semi-detached house and a twobedroom annexe next door accommodating seven people in total. It is situated in a busy road in Caterham near to all facilities and is indistinguishable as a care home, instead blending in well with the local community. All accommodation is of a very high standard. The home is owned by Westway Care Homes which a fairly recently registered service. The proprietor is also the manager of the home. Service Users have severe learning disabilities. All service users are male. The current fees charged range from£1,000 to £1,400 per week. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over three hours. Mary Williamson who is a Regulation Inspector carried out the inspection. The Registered Manager who is also the provider Mr Roshan Panchoo represented the establishment. A tour of the premises was undertaken and records relating to the care of the residents and the management of the home were examined. It was possible to meet all the residents in the home but only possible to talk to one in detail due to limited communication skills. Staff supported residents to use gestures and signs to communicate with the inspector. Discussion took place with staff, who all had a good knowledge of the needs of the residents they care for. Staff were also able to confirm the training they had undertaken and had a good understanding of the complaints and abuse awareness procedures. Records sampled included needs assessments, care plans, medication recording charts, individual activity programmes, menus, risk assessments, staff training records, and staff employment files. The Commission for Social Care Inspection would like to thank the residents, manager and staff for their help and hospitality during the inspection process. What the service does well: The home provides good quality care and support for the residents living there. The assessment process and the care planning are good with all residents having a detailed plan of care, which is updated regularly to reflect changing needs. The standard of accommodation is excellent providing residents with a comfortable and homely environment to live. The staff team are competent and have the training, and skills to meet the assessed needs of the residents they care for. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 6 The home is well manager creating an open and inclusive atmosphere. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information necessary to help them and their representative make an informed choice about the home. Needs assessments and contracts of occupancy are in place. EVIDENCE: There is a statement of purpose and service user guide in place, which provides prospective residents, their relatives, and care managers with the appropriate information necessary to make a choice about living at the home. This is also available in symbol format. Residents require a high level of support in making decisions. The manager demonstrated the assessment process prior to admission. There is a detailed assessment format in use for this purpose. Contracts of occupancy were seen. These outline the care provided, the accommodation offered, and the fees payable and by whom. Relatives or a representative from the funding authority sign these. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s needs are outlined in individual care plans, which also include needs assessments. Staff support residents to make decisions whenever possible. EVIDENCE: Care plans were randomly sampled. These are well written bases on the initial needs assessment, resident’s input whenever possible, and information from relatives. All aspects of physical, emotional, and social care are clearly documented and supported by objectives and goals. Care plans are reviewed regularly and updated to reflect changing needs. Care management reviews are held yearly. The manager stated that residents are offered choice in all aspects of daily life including when they get up and go to bed, a choice of menu, what they wear, and how they spend their leisure time. The communication skills of some of the residents are limited, and the manager stated that residents are supported to communicate with the use of signs, body language, and gestures. Staff were observed using gestures to communicate with residents. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 10 One resident stated that he is encouraged to make his own decisions on how to spend his pocket money and where he goes on holiday. Risk assessments are in place for all identified risks and are included in individual care plans. These include assessments for slips and falls, kitchen activities, use of the swimming pool, accessing public transport and for all activities within the home and in the community. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service encourages residents to take part in appropriate activities and to maintain family links. The nutritional needs of residents are met. EVIDENCE: Individual activity programmes are in place, and include sessions at The East Surrey College for literacy, art therapy, drama and movement. The manager stated that one resident has a voluntary job on a local farm, and another attends the Chaldon Centre day unit. The home is situated in the hart of the community and residents are supported to access all the local resources. One resident stated that he likes to buy cakes from the local bakery and enjoys going shopping in Caterham. Staff stated that they take residents shopping for clothes, organise trips to the pub, plan trips to the coast, and take residents to the local barbershop. One resident stated that he is looking forward to his holiday on the Isle of Wight in June. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 12 One resident attends church weekly by himself, or every two weeks with a friend. The manager stated that another resident attends church weekly with a member of staff. Family links are maintained and relatives and visitors are encouraged to visit the home at any reasonable time. Friendship groups are supported and one resident has an advocate. The kitchen is clean, and orderly, and domestic in appearance. The manager stated that residents are encouraged with support to make drinks. The staff prepare all meals. Menus are planned over a four-week cycle. These are compiled by staff with input from the residents and knowledge of individual likes and dislikes. The manager stated that the menus are approved by a dietician for nutritional content. The main meal is served in the evening. Lunch on the day of the inspection consisted of a selection of sandwiches, crisps, yogurt, and fresh fruit. All staff working in the home have a food hygiene certificate. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal care is offered to residents in the way they prefer as outlined in individual care plans. The physical, emotional and medication needs of residents are met. EVIDENCE: The arrangements in place to meet the health care needs of the residents are satisfactory. All residents are registered with a local GP and can visit the surgery when necessary. The manager sated that the GP is very supportive to the residents. Dental treatment is provided at the special needs dental unit at East Surrey Hospital. Chiropody treatment is accessed at the Dean Hospital and eye tests are arranged when necessary. There is psychology and psychiatric support available when required and the psychiatrist will review medication regularly. There is a medication policy in place for the administration of medication. All staff that administer medication are familiar with this policy and receive regular medication training to promote good practice. Medication is stored in the dining room in an appropriate cupboard. Townsend Chemist supplies medication in blister pack format. The pharmacist was undertaking an audit of medication during the inspection. The medication 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 14 recording charts were sampled. These are well maintained. Currently there are no residents in the home that self-medicate. Throughout the inspection staff were observed undertaking various aspects of personal care for residents in a respectful and professional manner. They were observed to be polite and address service users by their preferred name. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are protected by the home’s policies and procedures around concerns, complaints, and safeguarding vulnerable adults. EVIDENCE: The home has a complaints procedure in place, which is also included in the service users guide. All residents and relatives have access to a copy of this. The residents due to their communication skills and capacity are very much reliant on staff, relatives and advocated, to make a complaint on their behalf. This procedure was discussed with staff on duty who were aware of their responsibilities. There have been no complaints since the last inspection. The Oxford area office address was given to the manager in order to update this procedure. The home has an abuse awareness policy in place and all staff have training in this procedure during induction training. During discussion with staff they were able to demonstrate to the inspector their awareness of this procedure. There is also a copy of Surrey’s Multi Agency policies and procedures on Safeguarding Vulnerable Adults in place and the manager stated that he had attended training in these procedures and has cascaded the training throughout the staff team. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The general standard of the environment is excellent, providing residents with a safe, well maintained, homely and clean place to live in. EVIDENCE: The home was clean, tidy and well maintained. Communal space includes a large comfortably furnished lounge, leading to a well-furnished dining room. There is large garden to the rear of the home providing residents with ample space and unrestricted access. Bedrooms have been personalised to reflect resident’s personalities and interests. One resident stated that he liked his room and enjoys keeping it clean. He also stated that he keeps his room locked and keeps his key safe. There is a control of infection policy in place and the standard of cleanliness throughout the home is excellent. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A competent staff team supports residents. Residents are also protected by the recruitment procedure in place. EVIDENCE: The staff duty rota was seen and indicated that four staff work in the home throughout the day, which is sufficient to meet the assessed needs of the residents. There are also two staff employed for sleep in duties. The recruitment procedure in place protects the residents living in the home. Two staff recruitment files were sampled. These are well maintained and contain all the required employment documentation including two written references, employment history and a CRB (Criminal Records Bureau) disclosure number. There is training and development plan in place for all staff. The manager explained that all staff complete a one-month induction programme. Foundation training follows this. Health Care Safety Services provide all the training in the home. NVQ training is ongoing with several staff having achieved NVQ level 2 and two staff are now undertaking NVQ level 4. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from a well run home, which promotes their health, safety and welfare. EVIDENCE: The home is well managed by the registered manager who is also the provider. He is a registered nurse, and has an NVQ level4, and his Registered Managers Award (RMA). He also has the support of a deputy manager who is currently undertaking her NVQ level 4. An open and inclusive atmosphere was observed during the inspection with staff, residents, and managers interacting in a positive and respectful manner. Quality assurance is monitored and questionnaires are sent every year to relatives, and health care professionals with input to the home. Feedback is 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 19 monitored and acted upon. The returned questionnaires are retained on file for reference. Health and safety is promoted and there is a wide range of health and safety policies and procedures in place. All staff have been trained in health and safety procedures, manual handling, first aid, food hygiene, and COSHH. The fire safety procedures are good and fire alarms are checked weekly. Swift contractors maintain the maintenance of fire fighting equipment and emergency lighting. The procedure for recording accidents and incidence in the home is good. Risk assessments are in place for all identified risks and safe working practice. 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 39 Westway DS0000028581.V339060.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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